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Valvular Heart Disease (Boards and Beyond) (Rheumatic Heart Disease (Can…
Valvular Heart Disease (Boards and Beyond)
Systolic Valve Lesions
occur during heart contraction (squeeze)
Aortic Stenosis
Leaflets are fused or not moving
creates resistance
Main problem is stiff aortic valve
LV pressure in systole will be much higher than aortic pressure
increases Afterload: Wiggers: green curve must get much higher than red aortic pressure in order to make blood flow out of LV
Pressure volume loop: Right shift w/ higher afterload
Largely disease of elderly
calcification and fibrosis of aortic valve leaflets
wear and tear
Bicuspid aortic valve
50-60s
assd.
Marfan
Turners
Coarction of the aorta
Classic triad of AS
Heart Failure
hi LVEDP due to hi afterload
syncope develops
exercise won't increase CO: fainting
Chest pain/angina
hi LVEDP decreases coronary blood flow
Murmur: systolic crescendo-decrescendo
Treatment: valve replacement in only severe patients
Supravalvular AS
narrowing distal to aortic valve
Williams syndrome: gene deletion
Mitral Regurgitation
Blood leaks across mitral valve
Wiggers Diagram: blue line (LA pressure) increases during systole bc blood is crossing mitral valve into LA4›
PV loop: isovolumic contraction is disrupted, blood is leaking back
increases preload, increases SV
Causes
Often secondary to another problem
Dilated LV
Functional MR
leaflets are too far apart
ischemia
damage to papillary muscles
hypertrophic cardiomyopathy
If primary: MVP
degenerative myxomatous
Endocarditis
Rheumatic Heart disease (w/ MS)
Downs syndrome
endocardial fusion defects
assd w. cleft mitral valve (missing piece)
Symptoms:
HF symtoms
chronically high LV pressure
Pulmonary edema, dyspnea, LE edema
Murmur: Holosystolic murmur (Like VSD, TR)
Treatment: Surgery
Pulmonic Stenosis
presents in
children
Carcinoid heart disease
Tricuspid Regurgitation
R sided valvular diseases are rare
presents in IV drug users
bacteria in veins encounter tricuspid first
giant V wave on tracing
C-V segment is RV contraction, contraction therefore pushes blood into RA causing large V wave
Diastolic Valve Lesions
occur during heart relaxation
Aortic Regurgitation
Pathophysiology
blood leaks across aortic valve
Wiggers: Red curve is aortic pressure, normal high but abnormal low :
PV loop: disruption of isovolumic relaxation. Tilt shows blood entering LV
Increased preload and stroke volume
Murmur
blowing diastolic
Causes
often Dilated Aortic root
leaflets pull apart
due to HTN
Bicuspid aortic valves
#
Endocarditis
Rheumatic Heart disease
concomitant w/ mitral disease
Marfans/Turners
bicuspid Aortic valve and large aortic root
Syphilils
dilated aortic root (tertiary)
Clinical findings
classic: wide pulse pressure
Pdia in aorta is low because it leaks back
symptoms
water hammer pulses
strong bounding pulses
Head bobbing
dizziness due to low blood pressure
low Pdia=
Treatment: surgical
Mitral Stenosis
Leaflets cannot come apart
creates resistance to flow as blood moves from LA to LV
Wiggers: blue LA pressure should sit on top of green curve. But Theres a pressure gradient between atrium and ventricle !
PV loop: blue is MS heart. Ventricle is normal, so it has a normal shape but it is smaller than green curve/ low stroke volume
Clinical features:
usually consequence of RF
Rarely: Ca buildup in elderly
Most common symptom is dyspnea
pulmonary congestion from hi LA pressure
Other symptoms
hemoptysis
Afib
Stroke
Dysphagia and hoarseness
Large LA compresses nerves/esoph
Murmur:
diastolic rumble w/ opening snap
Treatment: Surgical intervention
Pulmonic Regurgitation
Hi pressures in lung pushes blood backwards
repaired ToF as child
endocarditis
rheumatic heart disease
Tricuspid Stenosis
presents
Rheumatic heart disease
usually in conjunction w/ mitral valve
Carcinoid heart disease
Large A wave in venous pressure tracing
a wave represents atrial contraction, there is a stiff tricuspid valve, creating large a wave
Rheumatic Heart Disease
post RF
50% don't recall having it
very rare in US: hygiene, antibiotics
Immigrants
asymptomatic till pregnancy
Can lead to regurgitation or stenosis
Mitral valve almost always involved
other valves problematic in addition to mitral valve
Aortic valve (20%-30%)
Tricuspid valve rarely involved (subclinical)
Afterload Reduction for AR and MR
#
#
in theory: afterload reduction can improve forward flow
in acute regurgitation this helps
ineffective in chronic disease
Both conditions remain surgical diseases
Test question: "Best medical option?"
choose the best medication for lowering afterload
Carcinoid Heart Disease
one of a few things causing R sided valvular lesions
tumors secrete 5-HT serotonin
Vasodilator
flushing and diarrhea
Must have metsto affect the heart
liver inactivates 5HT
mets in the liver can secrete 5HT that gets to the heart
Leads to fibrous deposits on tricuspid and pulmonic valve
5HT is inactivated by lungs
never see L sided lesions
Diagnosis
Urinary 5HIAA
Clinical presentation
Abn pain from tumor
FLushing
Diarrhea
Pulmonic and tricuspid valve disease
Valve Surgery
only done in modern era for severe valve disease
Valve repair preferred rather than replacement
an option for some mitral lesions
torn chordae tendinae
Bioprosthetic valve
porcine
bovine pericardial valve
cows pericardium sticked to make a valve
No anticoagulant required
Downside
degenerate over time
10-20 years
repeat operations are more risky
scar tissue in chest
use for older patients only
65
Mechanical Prosthesis
Single leaflet (tilting disk) or bileaflet devices
Require lifelong anticoagulation
usually <65 yo